Print an application

Applying for enrollment in UPMC for Life is easy

Follow the steps below to apply for enrollment in a UPMC for Life plan.

1. Choose the UPMC for Life plan to which you would like to apply for enrollment.
   Compare plan options and benefits.
   
   
2. Apply for enrollment. We offer three different ways to apply:
   • Call us toll-free at 1-866-400-5077 to apply for enrollment over the phone. TTY users should call 711.
   • Apply online using our secure enrollment website.
   • Print and mail your enrollment application. Click on the enrollment application for your area to download and print.
     
     Select One OH - Jefferson OH - Harrison PA - Adams PA - Allegheny PA - Armstrong PA - Beaver PA - Bedford PA – Berks PA - Blair PA - Bradford PA - Bucks PA - Butler PA - Cambria PA - Cameron PA - Carbon PA - Centre PA - Chester PA - Clarion PA - Clearfield PA – Clinton PA - Crawford PA - Cumberland PA - Dauphin PA – Delaware PA - Elk PA - Erie PA - Fayette PA - Forest PA – Fulton PA - Greene PA - Huntington PA - Indiana PA - Jefferson PA – Juniata PA – Lackawanna PA - Lancaster PA - Lawrence PA – Lebanon PA - Lehigh PA - Luzerne PA – Lycoming PA - McKean PA - Mercer PA - Mifflin PA - Monroe PA - Montgomery PA - Montour PA - Northampton PA – Perry PA - Philadelphia PA - Potter PA – Snyder PA - Somerset PA – Sullivan PA – Susquehanna PA – Tioga PA – Union PA - Venango PA - Warren PA - Washington PA – Wayne PA - Westmoreland PA – Wyoming PA - York
     
     
     Enrollment Application Form
     Enrollment Application Form
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     Enrollment Application Form
     
     After you have completed the enrollment application form, mail it to us at:
     UPMC for Life
     PO Box 2967
     Pittsburgh, PA 15230-9474
   
   
3. We will contact you once your enrollment application has been processed.

You can also enroll online via the Medicare website at Medicare.gov.